ANTIHISTAMINES: FIRST GENERATION | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ALLER-CHLOR 4 MG TABLET chlorpheniramine maleate	00536100601 RUGBY	Yes	No	Medicaid CSHCN
ALLER-CHLOR 4 MG TABLET chlorpheniramine maleate	00536100610 RUGBY	Yes	No	Medicaid CSHCN
ALLERGY 25 MG CAPSULE diphenhydramine HCl	70000020701 LEADER	Yes	No	Medicaid CSHCN
ALLERGY 25 MG CAPSULE diphenhydramine HCl	70000020702 LEADER	Yes	No	Medicaid CSHCN
ALLERGY 25 MG CAPSULE diphenhydramine HCl	70000059802 LEADER	Yes	No	Medicaid CSHCN
ALLERGY 4 MG TABLET chlorpheniramine maleate	00904001280 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN
ALLERGY RELIEF 25 MG SOFTGEL diphenhydramine HCl	70000058501 LEADER	Yes	No	Medicaid CSHCN
ALLERGY RELIEF 25 MG TABLET diphenhydramine HCl	70000013601 LEADER	Yes	No	Medicaid CSHCN
ALLERGY RELIEF 25 MG TABLET diphenhydramine HCl	70000013602 LEADER	Yes	No	Medicaid CSHCN
ALLERGY RELIEF 25 MG TABLET diphenhydramine HCl	70000013603 LEADER	Yes	No	Medicaid CSHCN